“Everything can be taken from a man but one thing: the last of the human freedoms — to choose one’s attitude in any given set of circumstances, to choose one’s own way.”
– Viktor Frankl, Man’s Search for Meaning
June 21, 1994 – Kigali, Rwanda
Dr. James Orbinski, an emergency medicine physician from Canada, was suddenly interrupted by cries for help. He was on duty, working as a volunteer for Médicins Sans Frontières (MSF), in the middle of the catastrophic Rwandan genocide. The local Red Cross Hospital was being overrun by patients. It was sheer chaos as hundreds of distraught and dying patients, screaming from gunshot wounds and machete injuries, flooded through the front gates. Mortar fire and bomb blasts provided a soundtrack to the pandemonium.
The number of patients and their injuries were overwhelming. The gutters surrounding the hospital filled with blood. Yet Dr. Orbinski, a veteran of multiple MSF tours, was prepared for this. One after the other, he stitched bowels, tied off arteries, and placed chest tubes, preparing the patients for the operating room.
Despite the efforts of the medical staff, the sheer number of patients with devastating trauma meant that many of them died before being seen. The situation was incredibly daunting, but Dr. Orbinski and his colleagues worked for over 16 hours straight. “On doit le faire,” they told themselves. “We have to do it.” Through the chaos and the tragedy, the shared sentiment strengthened their resolve and they toiled through the night trying to save whoever they could.
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The Highs and Lows of 2020
One year ago, I remember how excited I was for the start of the new decade. New decade, new me, I told myself. Obviously, I was not alone. My family members, friends, and colleagues also looked for the opportunity to psychologically set themselves anew and have a fresh canvas on which to paint their dreams, goals, and milestones. Of course, it later became painfully clear that 2020 had other plans.
The COVID-19 pandemic swept across the globe and overwhelmed healthcare systems in every country. Emergency medicine and critical care providers were caught off guard as hospitals became inundated by patients in respiratory distress. At the beginning, we did what we could with the limited knowledge that we had. More than once, we had to recalibrate our treatment strategies, from medications to ventilator management, as more experience and new data accumulated.
Unfortunately, despite the advances in our knowledge of the disease, the widespread advocacy of mask-wearing and social distancing, and the hopeful presence of a vaccine, the pandemic has yet to reach its peak. Many of us feel stressed from the unrelenting march of hypoxic patients into our hospitals and the grief when some perish despite our best efforts. Among medical personnel, who were themselves isolated from friends and family, it has unfortunately led to depression, burn out, and suicide. We were certainly unprepared for this level of suffering.
On the other end, we saw incredible acts of compassion, generosity, and courage. Day after day, resilient doctors, nurses, respiratory therapists, and techs continue to don their gear to treat, encourage, and console their isolated patients. Despite the despair I sometimes feel, I am buoyed and moved by the inspirational stories of the doctor hugging his patient who felt alone on Thanksgiving to the nurse helping her patient say goodbye to her family over Facetime to the residents who started a non-profit to collect and distribute PPE. These are some of best known examples, but many more acts of kindness are not publicized, occurring quietly between provider and patient. These anecdotes led me to wonder, why are some people able to thrive amidst the chaos?
You Have A Choice
Midway through the year, I was trying to cope with lost opportunity and compassion fatigue. My fellow residents and I lamented that we were losing a year of our lives. Meanwhile, family members were becoming sick, weddings were postponed, and trips and electives were being cancelled. Patients continued to visit the emergency department with worsening COVID symptoms. The country was mired in political strife and outlets for the cynicism we felt were limited.
Looking for guidance, I reached for Meditations by Marcus Aurelius, the Roman emperor. The book, written in the 2nd century AD, is his reflections on his internal struggle as he strived for personal growth and self-improvement while leading an empire. Meditations is now a foundation of Stoic philosophy, which is principally concerned with finding happiness by living a virtuous and just life.
At one point, Marcus Aurelius writes, “If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.” And then I began to understand. The people who continue to thrive despite incredible grief, the unrelenting work, the uncertainty, and the numerous obstacles do so because they choose to. It is a conscious decision. Rather than succumb to external factors that they cannot influence, they focus on their own judgements, attitudes, and actions, which they can control.
In an interview with University of Toronto magazine, Dr. Orbinski stressed this idea as a guiding force in his life as a humanitarian. “Every moment in your life is a choice, and we have a choice as to how we will see the world and how we will see ourselves in it, and therefore what we will do.” In other words, you have a choice in how you see yourself and how you respond to challenges. Naturally, the next question I asked was — how should I choose to be?
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Antifragile Systems
In his book, Antifragile, the options trader and philosopher, Nassim Nicholas Taleb set out to define a phenomenon he noticed in his work as a quantitative analyst. Traditionally, complex systems have been characterized by either their fragility (the ability to easily fail), their robustness (the ability to withstand failure), and resiliency (the ability to recover from failure) in the face of stress or volatility. Taleb noted a fourth state: anti-fragility. This is the property of a system to become stronger in situations of shock or chaos.
Think about how biological systems like bones and bacteria remodel and strengthen under stress. Or how about an artificial intelligence security program might “learn” from an attack and adapt a counter the next time. Or how a nimble start up might quickly pivot from one idea to the next after receiving feedback from users and absorbing market forces. These systems are antifragile. They are designed to endure duress and chaos, and after recovery, they gain from the disorder — they get better.
As resuscitationists and intensivists, we endured a tremendous amount of stress and pain in 2020. We cannot thrive and become the clinicians we aspire to be if we do not choose to be great. There were many days where I forgot to eat or use the bathroom because I was too stressed on shift. This affected my performance as a physician. Later, I collapsed in my bed at night dreading the next shift and the next patient. This is no way to practice medicine, let alone a life!
Taleb’s book offers many heuristics and strategies that might make your life and practice more antifragile. I have included a few of my favorites below, but I encourage you to read his book with the ironic caveat that he is an ornery writer who has a disdain for modern medicine and academia, despite having multiple advanced degrees.
Embrace stress, but allow yourself to recover: Our minds, personalities, and will power can also be antifragile systems. The adage, “What doesn’t kill you makes you stronger,” applies. The key is that we have to remember to nurture ourselves so that we continue to grow and learn from our experiences. We have to take time for renewal. We have to make time to eat and sleep. We have to say “no” to the extraneous. And we have to create spaces in our lives to process our experiences with loved ones so that we do not become depressed or burned out.
Via Negativa – Add more by subtracting: While society conditions us to believe that more is better, the first step to antifragility is to eliminate the downside. Taleb points towards instances in medicine to make his point. In the long run, eliminating junk food is better than getting bariatric surgery and removing the toxic people from your life will lead more dividends than adding new friends. I remember an attending teaching me that the true mark of patient improvement in the ICU is what interventions you remove, not what you add.
Build redundancy into your life: While optimization seems to be all the rage, antifragile systems are redundant. This eliminates the chance for a single point of failure from a random event. Perhaps this means having multiple accessible to do lists or multiple people aware of what a patient requires. Imagine that one patient needs blood ordered but you are suddenly called to a code. In all the excitement, it is very easy for that task to be forgotten. But if your system for reviewing your tasks is redundant, this is less likely.
Practice the barbell strategy: One of Taleb’s best insights is that life is inherently asymmetric. Most of the time, in volatile systems, only a few interventions will lead to a majority of the benefit (or harm). The barbell strategy aims to limit the downside of risk by balancing a stable plan with multiple small, risky bets. Keep practicing medicine, but why not take a stab at that book you’ve always wanted to write or the business you’ve always wanted to start. If it does not work out, no big deal. The barbell strategy allows you to protect yourself from catastrophic loss, while leaving you open for tremendous gain.
2021: The Year of the Antifragile Resuscitationist
Once again, as the calendar turns to 2021, I am assessing what the previous year taught me in order to set new intentions. In many ways, 2020 was the year of resiliency. We were blindsided and we are now finding our way back to our feet. Many of us are exhausted and discouraged. We want our lives and our families back. We want to give hugs and see smiles again. We want normalcy.
We will get there, but we have to dig our heels in for this final stretch. Ultimately, we have a choice in how we respond to adversity. We can despair, or we can reframe it as an opportunity to change, grow, and lead. The Stoics taught that how a situation affects us depends primarily on how we frame it. As an individual, you cannot control other people’s actions or the pandemic. But you can control your perceptions and therefore your response. With a strong, grounded attitude, you can serve as an example to your family, friends, and colleagues.
For 2021, I propose that we choose to be antifragile. Let’s strive to become more than resilient and robust. Let’s grow stronger when faced with adversity. By making a conscious effort to get rid of negative habits and thought processes, developing a system that resists failure, and taking strategic shots at your dreams, not only can 2021 be a tremendous opportunity for your practice as a resuscitationist, but also your life.
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December 10, 1999 – Oslo, Norway
Far away from the mayhem of war, Dr. Orbinski stood in front of an impeccably dressed audience in a gilded auditorium. Only one year into his term as the President of Médicins Sans Frontières, he had just accepted the Nobel Peace Prize on behalf of the organization. “Our action is to help people in situations of crisis,” he said. “Humanitarian action is more than simple generosity, simple charity. It aims to build spaces of normalcy in the midst of what is profoundly abnormal. More than offering material assistance, we aim to enable individuals to regain their rights and dignity as human beings.”
Everyday, healthcare providers work to ensure the dignity of their patients. It is challenging and sometimes chaotic. Some days, my patience is short and I am easily frustrated. I have to remember to be kind to myself. I am human, after all. But I also remind myself that I am lucky to be in this position to help and treat those who were dealt a far terrible hand. It is the life of service that we chose. So everyday, I don my PPE and aim for antifragility. It’s hard work, but we owe it to ourselves and our patients. On doit le faire.
The Debrief
- Why are some people able to thrive in chaotic or disordered environments? Most likely because they choose to thrive rather than succumb.
- Stoicism teaches that we have a choice in how we respond to external factors. While we cannot control an outside stimulus, we can control our feelings, thoughts, and responses.
- Complex systems have been characterized by either their fragility (the ability to easily fail), their robustness (the ability to withstand failure), and resiliency (the ability to recover from failure) in the face of stress or volatility. There is a fourth state: anti-fragility. This is the property of a system to become stronger in situations of shock or chaos.
- Antifragility leads to strength when one is able to properly recover after a stress. In order to be antifragile resuscitationists, we must choose this path.
- While 2020 might have been the year or resiliency, let’s make 2021 the year of antifragility. Let’s choose to thrive, no matter what we are faced with.
From all of us at CriticalCareNow.com, wishing you and yours a happy, healthy, and abundant 2021! Happy New Year!!!
References
- Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy. New York: Simon & Schuster.
- Gibson, S. “A Doctor in Kigali.” University of Toronto Magazine. https://magazine.utoronto.ca/research-ideas/culture-society/james-orbinski-profile-doctors-without-borders-canadians-in-rwanda. Accessed 28 December 2020.
- Marcus Aurelius & Hays, G. (2002). Meditations. New York: Modern Library.
- Orbinski, J. (2008), An imperfect offering: Humanitarian action for the 21st Century. New York: Walker Books.
- Orbinski, J. “The Nobel Prize Speech.” Médicins Sans Frontières, https://www.msf.org/nobel-peace-prize-speech. Accessed 28 December 2020.
- Taleb, N. N. (2012). Antifragile: Things that gain from disorder. New York: Random House.
